Session Information
Session Title: AA 2021 Virtual Posters - Pandemic
Session Time: None. Available on demand.
Disclosures: Julia Fram, MD: No financial relationships or conflicts of interest
Case Diagnosis: A 73-year-old male with schizophrenia, recent cervical myelopathy, and COVID pneumonia.
Case Description: A 73-year-old male with schizophrenia presented to acute care for progressive weakness and falls and was found to have cervical myelopathy and COVID pneumonia. His COVID pneumonia was treated with remdesivir and dexamethasone and cervical myelopathy managed non-operatively. His course was complicated by bradycardia, urinary retention, B12 deficiency, and delirium. On admission to an inpatient rehabilitation facility, the patient remained delirious and required maximum assistance on mobility and self-care tasks. In evaluating possible etiologies, the clozapine trough drawn at acute care resulted at a toxic level (clozapine = 984 ng/mL, norclozapine = 497 ng/mL) with a normal absolute neutrophil count. Previously, he had been stable on 400 mg clozapine nightly, lamotrigine and mirtazapine. After psychiatry consultation, his clozapine dose was reduced to 200 mg daily for one week followed by 300 mg daily with improvements in delirium.
Setting: Inpatient rehabilitation facility (IRF).Assessment/
Results: His serum level returned to normal range on this dose (clozapine = 450 ng/mL, norclozapine = 242 ng/mL). Once therapeutic, he had significant improvements in participation, agitation, sleep-wake cycle, and functional measures ultimately requiring only supervision or touching assistance for the majority of self-care and mobility tasks at discharge.
Discussion: Clozapine toxicity had previously been documented in patients with systemic inflammation, but during the pandemic few cases have been documented in the setting of COVID-19. Symptoms of clozapine intoxication include sedation, ataxia, seizures, and EKG abnormalities.
Conclusion: In a patient with COVID infection, clozapine levels and complete blood count with differential should be monitored, and an empiric decrease of clozapine dosage should be considered.
Level of Evidence: Level V
To cite this abstract in AMA style:
Fram J, Lloyd RB, Cowley N, Stone S. An Atypical Decline: How a Toxic Level of an Atypical Antipsychotic (Clozapine) in a COVID-19 Positive Patient Resulted in a Functional Decline: A Case Report [abstract]. PM R. 2021; 13(S1)(suppl 1). https://pmrjabstracts.org/abstract/an-atypical-decline-how-a-toxic-level-of-an-atypical-antipsychotic-clozapine-in-a-covid-19-positive-patient-resulted-in-a-functional-decline-a-case-report/. Accessed May 21, 2025.« Back to AAPM&R Annual Assembly 2021
PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/an-atypical-decline-how-a-toxic-level-of-an-atypical-antipsychotic-clozapine-in-a-covid-19-positive-patient-resulted-in-a-functional-decline-a-case-report/